The skin envelope is the largest organ of the human body. In that regard, it is also one of the earliest indicators that the biological systems that keep an individual “well” may be out of balance. This is a primary reason I routinely have prospective patients complete a medical questionnaire, undergo premedical testing, and obtain medical clearance from the patient’s personal physician. As an appearance-enhancing surgeon, I want to know if a health problem exists. It helps me determine the nature and extent of the treatment I recommend for each patient and the facility in which it is to be performed.

Rather than simply treating the visible signs of aging, appearance-enhancement professionals in my institute provide skin condition assessments. They also provide therapies that are designed not only to make the skin look better, but also to help restore the skin after the ravages of aging and years of sun and wind exposure, from the inside out.

■ Nonsurgical Rejuvenation Procedures

A variety of procedures and products that camouflage the signs of aging are available. And the numbers grow with each passing year. Young facial surgeons can expect to be bombarded by sales representatives offering “the latest” technology or a machine/device that “every aesthetic surgeon must have in their practice.

My advice is to “go slowly.” Think twice—and thrice—before purchasing or entering into a long-term lease for expensive equipment. Technology changes so rapidly that before the first machine is paid off, it is “out of style.” Seek companies that will lease equipment—and in some cases, operators—on a daily basis. These companies will bring the equipment to your office on days you have patients scheduled and take the equipment away after the last patient is treated.

I have a standing practice of asking sales personnel to provide histological proof from independent researchers to verify claims made by the company selling a product, device, or piece of equipment. In too many cases, such evidence is not forthcoming. I interpret such inaction as meaning no evidence exists.

Clearly advanced skin care programs and products can give one’s skin a more youthful appearance. Medical-grade, injectable fillers provide temporary improvement in wrinkles and hollowed areas caused by aging, but many clients are looking for more. They want to be as healthy as they look and look as healthy as they are. And they want these things longer than some of the temporary therapies can provide. More importantly, patients deserve to know the pros and cons of temporary therapies, as compared with more permanent alternatives. As part of a physician’s “informed consent” regarding treatment, the alternatives should be discussed prior to treatment.

Fig. 11.3 (a) Prior to skin polishing. (b) After skin polishing.

It is important that facial surgeons and aestheticians alike realize—and communicate to their patients/clients—that the vast majority of nonsurgical rejuvenation therapies are designed to produce temporary results. Longer-lasting results—and lasting provider-client relationships—are realized when patients are duly informed about the cost/benefit ratio of products and procedures recommended. Patients also benefit when the skin care professionals providing nonsurgical procedures and products work hand in hand with facial surgeons, and vice versa.

■ The Skin as an Indicator of Health or Illness

Human skin is an indicator of conditions that exist beneath it. Undiagnosed medical conditions (hormone imbalances, thyroid deficiencies, collagen disorders, poor nutrition, stress, etc.) are often reflected in the appearance and texture of one’s skin. It is for this reason that a physician should be involved with any “skin care center” or “spa.”

Skin care, nutrition, and weight and age management should be approached from both directions: inside out and outside in. In that respect the skin should be viewed as a two-way mirror.

From a blood sample, a facial surgeon can determine whether a prospective patient’s hormones are out of balance, whether the patient needs to supplement their diet, or whether indicators of biological imbalance of the patient’s internal organ systems exist. If it is determined that imbalance is present, a rejuvenation specialist can recommend the appropriate corrective measures prior to undertaking a surgical procedure requiring optimal healing. In some cases, referral to the patient’s personal physician or a medical specialist is indicated.

It is virtually impossible to separate an individual’s appearance from their health. Over the years, I have found that patients who do the things that are required to look their best tend to find better health, even if finding better health was not their primary objective when consulting me.

■ Weight Management: Its Effect on Skin, Health, Aging, and Facial Features

It should come as no surprise that as an individual gains weight, the skin surrounding the face and body substructures is stretched, making those structures even more susceptible to premature sags and bulges, especially if the individual loses large amounts of weight. Roller-coaster weight swings can be even more damaging. Each time the skin is stretched, elasticity is lost. The process leads to sags and droops throughout the entire body. This fundamental—and documentable—characteristic of the skin of mammals lies at the heart of using “tissue expanders” or “serial excisions” in reconstructive surgery.

During consultation, I am often asked if weight gain or loss will affect the treatment plan I recommend. My answer to patients is this: “A 10- to 12-pound weight swing will make very little difference. If you plan to lose more than that, let’s wait until you get to within that 10 to 12 pounds of what you think your realistic weight will be.”

Another fundamental principle of nutrition and health applies here. When a body is losing weight, it is in a catabolic state, that is, it is cannibalizing itself through a process known to biochemists as “negative nitrogen balance.” First stored carbohydrates are cannibalized, then fat, and finally, muscle. I recommend that any patient engaged in a weight reduction program reverse the process to an anabolic state (positive nitrogen balance) prior to undergoing surgery. It is my hypothesis that not doing so is why patients undergoing surgical procedures following massive weight loss do not heal as well as other patients.

I also explain that managing one’s weight is not nearly as complicated as one might think. It is a matter of self-discipline and keeping score—balancing the number and kind of calories ingested each day with the number of calories expended while one goes about one’s daily routine. Clearly, more physical activity burns more calories. But exercise alone has not proven to be the answer to weight management. For example, one must walk a mile (at a rapid pace) to burn off the number of calories that one takes in with two cookies, a nondietetic drink, or a small piece of cake or pie.

I now share with you the conversation I have with my patients who are serious about losing weight. Most commercial “diet” plans are product (and profit) driven. The client is expected to purchase the meals produced by the company.

In truth, a bit of nutritional education allows clients/patients to do their own shopping and meal planning, at great savings.

■ Treatment and Product Options for Creating More Youthful Skin

The skin of the face is the draping under which the skeletal, muscular, and adipose architecture exists. It is also the focus of skin resurfacing procedures (laser therapy, chemical peels, and dermabrasions) that provide a more youthful, vibrant external appearance. In the hands of a well-trained facial surgeon, each of these skin resurfacing modalities is effective. What is not equal is the expense factor in providing chemical peeling, dermabrasion, or laser therapies to the skin. The cost (to the physician) of the supplies and chemicals of a peel is usually less than $100 for a dozen or more cases. The cost to purchase a level II and III dermabrasion machine and abrasive brushes is in the range of $2,000. The cost to purchase a laser can range from $35,000 to more than $100,000. The life span of a level II or III chemical peeling formula is a lifetime. The life span of a dermabrasion unit and brushes is a decade. The life span of the most expensive treatment modality (a laser machine) is 5 to 7 years. The surgeon should also explore the cost of maintaining a laser over that span of time. I once heard a colleague say to an auditorium full of colleagues, “Before I came to this meeting, I visited one of the storage rooms in my office. I did a quick survey and determined that I had approximately a million dollars’ worth of outdated lasers and noninvasive equipment doing nothing but collecting dust in that room.”

With the appropriate training and experience, a facial surgeon can achieve the same—or very similar—results with any of the three methods of skin resurfacing. The message from a colleague who has tried and tested each skin resurfacing modality is this: Do the math. Obtain the training. Deliver more, for less.

■ Smart Nutrition: Feeding the Skin and Its Contents

As a biological organ, the skin of a human being relies upon proper nutrition— and all factors related to the metabolism of each ingested building block—to produce youthful, healthy cells during each phase of the process that many of us learned about in high school biology called “mitosis,” or “cell division.”

As is the case with a maturing baby, if deprived of essential foods, vitamins, and minerals, the baby fails to develop properly. In that respect, each new cell of the skin is a “baby” cell and must be nourished accordingly.

■ Hormone Balancing for Women and Men

Earlier I said that facial surgeons must think of themselves—and recommend treatment—first as a physician, to whom their patients entrust their care.

There is no debate among health care professionals that hormone levels drop with every year past the age of 30. In women, the process happens rapidly, causing obvious changes in the way a woman feels and looks—a condition known as menopause.

In men, the process is known as andropause, and it occurs more gradually— often sparing men the flash sweats, mood swings, and fluid retention. However, by the age of 50, both men and women experience measurable drops in the hormones that sustained a youthful appearance and heightened performance and positive outlooks on life. And making sure that the patient’s hormonal system is “in balance” lets the patient know that a facial surgeon will do everything possible to enhance the health and appearance of every individual who entrusts their care to that surgeon. It is the demonstration of such a commitment that solidifies the long-term doctor-patient relationship this book emphasizes. In addition, a healthy hormonal system enhances the work performed by a facial surgeon, and the way a patient feels.

In today’s complex, highly regulated—and highly publicized—medical environment, going above and beyond what is generally expected is the exception rather than the rule. There is no reason why holistic-minded facial surgeons cannot create a new “normal,” at least within their practice setting. Not only does a facial surgeon have the opportunity to do so, but the fact that the opportunity exists could raise it to the level of a responsibility.

■ The Stress Factor: Speeding Up the Aging Process and How to Slow It Down

As both James Allen and Dr. Orison Marden pointed out, it is how one responds to pressing circumstances that determines those circumstances’ effects on the body, and on the mind. Some people absorb stress as a sponge takes on water. Others shed it as Teflon sheds water. The “sponges” of the world are much more apt to experience the physical and mental effects of stress than “Teflon people.” Facial surgeons are more likely to see the sponges seeking their services and being willing to deal with their reasons for requesting surgical intervention.

Stress may be one of the most manageable enemies to longevity, productivity, and happiness. That having been said, stress relief may be one of the ways to arrest many of the unwanted signs and symptoms of aging. That is why, in my patient information book, I include a chapter on stress, grief, and loss management.

The holistic-minded, patient-oriented facial surgeon is both able and willing to share these fundamental truths with patients. A period of aerobic exercise, relaxation, or meditation is one way to “let go” of pent-up stress. A professionally administered “therapeutic facial” or massage relaxes muscles, lowers tension levels, and creates the release of the body’s own natural chemical relaxants and painkillers (endorphins.) This—coupled with reflexology therapy and a peaceful, professional environment—allows one to let go of the kinds of tension that promote premature aging and interfere with productivity in the workplace.

When the pressures of stress or the weight of grief becomes too heavy to manage with the aforementioned therapies, facial surgeons who have developed the kind of relationship with their patients that this book advocates are in a position to recommend the services of a licensed counselor or therapist. They are able to explain to their patient that asking for help under these circumstances is not a sign of weakness, but a demonstration of wisdom.

Imagine the possibilities when facial surgery is viewed—not as a procedure-driven profession—but as a specialty that expects its practitioners to invigorate and enhance their patient’s mind, face, body, and soul.

■ An Example of Tilting the Scales of Opportunity